Description:

PACCT-1 TAILORx Follow-up Form NCT00310180 Hormone Therapy With or Without Combination Chemotherapy in Treating Women Who Have Undergone Surgery for Node-Negative Breast Cancer (The TAILORx Trial) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=05DF4324-6BB2-192D-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=05DF4324-6BB2-192D-E044-0003BA3F9857

Keywords:
Versions (5) ▾
  1. 8/26/12
  2. 1/8/15
  3. 6/8/15
  4. 6/8/15
  5. 9/20/21
Uploaded on:

September 20, 2021

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License:
Creative Commons BY-NC 3.0 Legacy
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PACCT-1 TAILORx Follow-up Form NCT00310180

No Instruction available.

  1. StudyEvent: PACCT-1 TAILORx Follow-up Form
    1. No Instruction available.
Header
Follow-up Report Period
Follow-up Report Period (since registration - Choose one x)
Reporting period
Breast: Vital Status
Patient Vital Status
Primary Cause of Death (if applicable)
Breast: Disease Follow-up Status
Breast: Notice Of Progression - Advanced Disease
Has the patient been diagnosed with first ipsilateral breast tumor recurrence (since submission of the last follow-up form)
Method of Diagnosis (For contralateral breast primaries:)
IBTR histology (NOTE: See TAILORx Forms Completion Guidelines for IBTR definitions)
Iib - Local-regional Recurrence
Has the patient been diagnosed with first local-regional recurrence or progression (since submission of the last follow-up form)
Site of first local-regional recurrence (s check all that apply; all sites refer to the same side as the original primary)
Method of Diagnosis (For contralateral breast primaries:)
Iic - Distance Recurrence
Has the patient been diagnosed with first distant recurrence/progression? (since submission of the last follow-up form)
Site(s) of First Distant Recurrence (Indicate - check all that apply at the completion of the metastatic workup)
Method of Diagnosis (For contralateral breast primaries:)
Section Iii - New Primary Cancers
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
Method of Diagnosis (For contralateral breast primaries:)
Section Iv - Treatment
Has the patient received any chemotherapy during this reporting period?
Has the patient received any hormone therapy during this reporting period?
Did patient switch type of hormonal therapy during this report period
Specify reason for switch in endocrine therapy (If yes,)
Specify new type of hormonal therapy given
Specify which Aromatase Inhibitor was given (If aromatase inhibitor:)
Tamoxifen (Answer Yes or No for each of the following therapies the patient consistently took during this reporting period:)
Aromatase Inhibitor
Specify which Aromatase Inhibitor was given
Other
Did patient receive Ovarian Function Suppression (OFS) during this follow-up period?
Ovarian Function Suppression Type
Was all hormonal therapy discontinued this report period
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